With Congress and the Trump administration debating the Affordable Care Act (ACA), a new book proposes that states take the lead in healthcare reform and Washington facilitate the transition rather than dictate every move.

“The federal ACA was designed in the image of a 2006 state law that was crafted to address challenges that were unique to Massachusetts,” said Jim Stergios, executive director of Pioneer Institute in Boston, which published U-Turn: America’s Return to State Healthcare Solutions. “After an ill-advised attempt to redesign one-sixth of the U.S. economy, the country should encourage states to design reforms that meet their specific needs, and enable a real marketplace for healthcare to develop.”

Competitive federalism
Regardless of the fate of the ACA, authors Tom Miller and Jim Capretta of the American Enterprise Institute write that the states will need to move ahead. They propose a combined federal-state effort called “competitive federalism” to encourage flexibility and unique approaches, the most successful of which could be adapted and improved by other states.

“If each level of government plays its proper role, reforms can keep rates of coverage and quality of care high, while reining in cost increases,” Pioneer Institute’s Senior Fellow in Healthcare Joshua Archambault added. “Until Washington, D.C. recognizes that New Mexico is not the same as New Hampshire when it comes to healthcare, we will not achieve the systems that best serve patients.”

Fixing a broken system
The authors cite the current employer-based insurance system and heavy reliance on Medicaid for coverage as reasons why “economic dysfunction” has long plagued the U.S. healthcare market.

Making health benefits tax-free to avoid wage controls might have seemed an innocent loophole during World War II, the authors maintain, but the codification of this rule made it prohibitively expensive for Americans to buy coverage on their own; coverage that may suit them better than employer-provided benefits. In addition, larger employers’ health benefits are structured to be exempt from state healthcare regulations, making it difficult for states to craft serious system-wide reforms.

Miller and Capretta argue that the situation is made worse by dysfunctions in Medicare that harm the commercial insurer market, and low Medicaid reimbursement rates that shift costs onto the private insurance market.

“Hospitals and physicians have organized themselves almost entirely around Medicare’s rules, with virtually no input from state governments and little thought about whether that system makes sense for the care of non-seniors,” Archambault says.

The authors identify three key elements necessary for a competitive federalist solution: a refundable tax credit for health insurance, the creation of state-run high-risk pools, and Medicaid block grants.

Refundable tax credit
There has been spirited debate over refundable tax credits, largely because too little attention has been paid to revising regulations that unnecessarily drive up the cost of insurance.

“We should be able to walk and chew gum at the same time,” said Stergios. “Any healthcare solution must address regulatory issues and recognize that a refundable tax credit is critical to ensuring that the proposed healthcare ‘fix’ provides broad coverage.”

U-Turn argues that the federal government should:

Convert the current tax preference for employer-paid premiums into a refundable tax credit, starting with workers in small firms and individuals lacking stable employer-based health plans; and

Require that insurers offering coverage to tax credit-eligible families and individuals set an upper limit on consumers’ health expense exposure.

At the same time, state governments should administer the refundable tax credits, determining:

What health benefits, if any, to require in benefit packages offered by insurers selling to tax-credit-eligible consumers;

The manner by which state citizens would sign up for insurance coverage, and the benefit information that would be made available to help them make informed decisions; and

Equitable ways for private insurers to share the burden of covering the state’s sickest patients.

High-risk pools

The federal government should protect those with pre-existing conditions by using capped annual appropriations to finance state-administered high-risk pools.

Within a federal framework, states should set “guardrails” for those transitioning from employer-based insurance to the individual market. One option would be to cap premiums so high-risk enrollees can maintain continuous insurance coverage. In doing so, states should be given wide latitude to determine eligibility and penalize insurers that push those who are not truly high-risk into the publicly subsidized high-risk pools.

Medicaid reform

The federal government should convert the federal portion of Medicaid into a per-capita block grant.

States should support able-bodied, low-income adults by moving them into private insurance options with need-based premium support. Using their authority to regulate benefits, premium assistance, and other insurance market features, states could also design a refundable tax credit to serve Medicaid-eligible individuals. Enrollees would be allowed to choose among competing plans that represent different service models, but would face higher costs for more expensive plans.

“Despite years of effort and mountains of regulations, the federal government has been unable to screen for quality and act on that information,” concludes Stergios. “It is time for states and the federal government to hit the reset button.”With a robust federal-state partnership, the authors write, Americans will get a more affordable and more patient-focused health system, with high-quality care, predictable expenses, and more consumer choice.

About Pioneer:
Pioneer Institute is an independent, non-partisan, privately funded research organization that seeks to improve the quality of life in Massachusetts through civic discourse and intellectually rigorous, data-driven public policy solutions based on free market principles, individual liberty and responsibility, and the ideal of effective, limited and accountable government.